The Voice of Podiatrists

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December 08, 2008 #3,419 Editor-Barry Block, DPM, JD

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NY Podiatrist Sees “Theoretical Basis” for New Heel Pain Treatment

Italian researchers say they've developed a fast, effective, non-invasive treatment for the painful foot condition known as plantar fasciitis. Using a combination of "dry-needling" and steroid injections guided by ultrasound, the researchers say their approach achieved a 95 percent success rate in tackling a condition that afflicts about one million Americans every year and accounts for up to 15 percent of all foot problems.

Dr. Johanna Youner

Dr. Johanna Youner, a New York City podiatrist and a member of the American Podiatric Medical Association, said that while the combination of steroids and dry-needling may be novel, the use of steroids itself is not.

"But what is interesting," she added, "is the notion of using dry-needling -- that is poking at the inflamed area repeatedly. This would increase the trauma to the area a little, and by doing that increase blood flow. That is not a traditional treatment. And it might seem counterintuitive. But when you increase inflammation and blood flow to an area you can help it heal faster. And the fascia itself is a ligament that does not have a lot of blood flow, so it heals slowly. So this could theoretically help."

Source: Alan Mozes, HealthDay,[12/1/08]

VA Podiatrist Organizes Holiday Shoe Drive

Foot doctors across Virginia and The Salvation Army are teaming up for the 19th year to put shoes on the feet of the less fortunate. The Salvation Army and Charlottesville area businesses are asking people to drop off pairs of new or gently used shoes at The Salvation Army to be distributed to the homeless in February.

Dr. Sam Schustek

"Unfortunately there are many people who do not have properly fitting shoes. Also, with the cost of shoes, it's difficult for people to afford decent shoes," said organizer Sam Schustek. "Unfortunately, people need good footgear because they're on the street in the cold and the ice." The Shoes for the Homeless drive has collected and distributed more than 75,000 pairs of shoes in the Charlottesville.

Source: Liz Nagy, NBC-29 [12/5/08]

Alleged Failure to Attempt Conservative Care (Indiana)

Facts: Marcia Ellerbrook, age 55 was suffering from "heel spurs." She consulted on the matter with defendants. The doctors attempted a course of conservative care that included a Medrol dose pak, ice and elevation, trigger point injections, and strappings. Apparently, however, the doctors felt the conservative treatment was not working, and so they recommended a different approach.

Specifically, the doctors recommended that Ellerbrook undergo a plantar fasciotomy on both feet. Ellerbrook agreed to that plan, and the first procedure was performed on her left foot. Three weeks later, the same procedure was performed on her right foot.

Ellerbrook would later contend that the surgeries not only failed to improve her condition, they actually made matters worse by rendering her unable to continue working. She submitted the matter to a medical review panel comprised of three podiatrists. They were Dr. Carl Goodin of Lawrenceburg, Dr. Scott Schulman of Noblesville, and Dr. Barbara Hiskes of Crawfordsville. According to Ellerbrook, the defendants should have continued with conservative treatment prior to conducting the surgery. The medical review panel agreed and unanimously found that Defendants breached the applicable standard of care. Ellerbrook filed suit and reiterated her claim as outlined above.

The defendants defended the case and insisted that both the type and duration of the conservative care they provided to Ellerbrook were appropriate. Defendants also denied that Ellerbrook's inability to continue working was due to her foot surgeries. Rather, Ellerbrook could no longer work due to other medical conditions that included neck and back problems. The case was tried for five days in Evansville. During the trial, Ellerbrook asked the jury to award her damages of $1,500,000. Instead, the jury returned a defense verdict.

Result: Defense verdict on liability.

Plaintiff Experts Witnesses: Irwin Malament, DPM of Indianapolis, IN and David Powell, DPM of Evansville, IN. Dr. Malament is former President of the Indiana Podiatric Medical Association.

Defendant Expert Witnesses: Jeffrey Niespodziany, DPM of Mishawaka, IN and Alan Jacobs, DPM of St. Louis, MO.

Source: Indiana Jury Verdict Reporter

Slight Pay Bump Expected For Advantage Plans

Medicare Advantage plans are expected to get paid 14% more than traditional fee-for-service in 2009, a slight uptick from 2008, according to new data released at the Medicare Payment Advisory Commission’s December meeting. At least 9.9 million beneficiaries were enrolled in Medicare Advantage plans this year, a 16% increase from 2007. It’s estimated that Advantage plans were paid 13% more than traditional fee-for-service Medicare in 2008.

Among the various Advantage plan types, the controversial private fee-for-service plans will be getting paid 18% more than traditional Medicare next year, MedPAC researchers said during a presentation.Advantage plans are paid according to a bidding system, where plans bid against county-specific levels, or “benchmarks,” established by the Medicare program. Advantage plan benchmarks and bids are also expected to exceed traditional Medicare levels in 2009.

The commission previously recommended that the CMS reset Advantage plan benchmarks at 100% of traditional fee-for-service costs. “We plan to re-run that recommendation in our March (2009) report,” MedPAC Chairman Glenn Hackbarth said. On other payment issues, the commission mulled over a draft recommendation to increase Medicare physician payments by 1.1% in 2010, the same increase doctors will receive in 2009.

Source: Jennifer Lubell, Modern Healthcare [12/5/08]

Query: Persistent Pain and Numbness in Foot

I have evaluated a 44 year old female patient with persistent pain and numbness in the left lower leg. Originally, she had pain from the back down the entire leg. She had a lower back spinal fusion and that alleviated all the back, hip and thigh pain. However, she was left with distinct pain/neuritis with palpation along the course of the sural nerve from the lateral foot carried proximally to a few inches proximal to the malleolus.

NCV/EMG shows possible left S1 radiculopathy with relative prolongation of left posterior tibial F wave latency. There is no EMG evidence of changes in S1 innervated muscles and no evidence of left peroneal neuropathy at the fibular head. MRI of leg and ankle are unremarkabe. Spinal epidural and localized corticosteroid injections of the area offered no relief. Lyrica and Neurontin were not tolerated. Any other suggestions besides TENS or E-stim?

Robert M. Przynosch, DPM, Asheville, NC

RE: Comparators in Podiatric Research (Michael Turlik, DPM)
From: Elliot Udell, DPM

Dr. Turlik elucidates another very important component of medical research that is underutilized. He referred to this as the use of a "comparator" and clearly showed that we can set up our research projects to either compare a new medication to a placebo or to one that is already used and considered a "gold standard." This type of research where we compare products to each other is both not used enough and definitely not used in all ways that can help the public. For example, there are products that have gone generic such as older topical antifungals and even herbals, such as tea tree oil-based compounds which may cost a couple of dollars a tube. Research should be done to compare the efficacy of these inexpensive antifungals to the newer ones that cost our patients a hundred dollars a tube.

Such research findings could save our patients thousands of dollars as well as our healthcare system that often pays for medications. Unfortunately, most of the research done in this country is funded by the companies that don't want us to use generic and natural products and they have no economic interest in finding out how older generics or natural products compare to the ones they are currently spending millions of dollars to market.

Elliot Udell, DPM, Hicksville, NY, Elliotu@aol.com

RE: HMOitis and Research
From: Dennis Shavelson, DPM

HMOitis has created another monster. Insurance companies unwilling to pay for advances are playing the “double-blind study” card to justify not paying for care. EBM is one more term they added to my lexicon. New discoveries must withstand research as to positive outcomes, but now double-blind studies must be performed to “prove” the care payable, even if thousands benefit clinically. Excuses abound: When a company funds studies, “there was bias” by the investigators. 65 patients in a study is not large enough. A one-year study doesn’t have enough follow-up.

Part of medicine is skepticism to weed out new ideas that are not viable or even harmful. Insurance companies are infusing skepticism into our veins with blinding side-effects. Another part of medicine is open-mindedness. Medicine needs to try new paradigms of care. EBM’s are making open-mindedness vestigial! What we do is called practice not perfect.

In 1994, I was one of the first to market in-office dispensing to podiatry. in 2001, I placed the first Ossotron in New York City. There was interplay of ideas, debate and reaction to these changes, but they have all become a part of peer podiatry practice. There are great advances in podiatry on the horizon: eEpidermal nerve fiber density testing, Manuka honey, integrative care, and even new paradigms in biomechanics. My fear is that unless we develop a pipeline for investigating new concepts and ideas that currently don’t exist, or educate the public that we have “out-of-plan” treatments not covered by insurance, we are being manipulated to turn up our skepticism and shut down our open-mindedness. Medicine is becoming less fun, less sophisticated, less caring, and less profitable.

Dennis Shavelson, DPM, NY, NY, drsha@foothelpers.com

RE: Physician Documentation for Established Patients Is Still Lacking
From: Simon Young, DPM

I thought we were supposed to have less paperwork rather than more. It seems documentation is more important than diagnosis or treatment. We need higher reimbursement in order to comply with all this excessive and often unnecessary paperwork. The concept of seeing more patients for less money is inconsistent with the documentation goals. Something will have to give.

Simon Young DPM, NYC, NY, simonyoung@juno.com

PODIATRISTS NEEDED - CHICAGO -- NW IND & BALTIMORE/WASHINGTON, DC

Home Physicians, a medical group specializing in house calls is looking to hire podiatrists in Chicago, Northwest Indiana, and Baltimore, MD. Full and part-time positions are available. Competitive Compensation including malpractice. Contact Scott Schneider. Phone-773-342-4201 FAX 773-486-3548-E-Mail sschneider@homephysicians.com Visit our website

PRACTICE FOR SALE – CONNECTICUT

Well-established. Grossing 200K; Norwalk/Westport CT. Dr. recently deceased. High Volume Medicare ; NO BROKERS; Please email: berist92@gmail.com

ASSOCIATE POSITION – ST. LOUIS, MISSOURI

Excellent opportunity for PSR 24-36 foot and ankle surgically-trained physician. Looking for hard-working, personable, highly-motivated individuals to join our group and build their own practice. Position leading to partnership. Great opportunity with excellent salary and benefits. Please e-mail CV and references to cavallinig@foothealers.com

ASSOCIATE POSITION- BALTIMORE, MARYLAND

Busy practice in the Pikesville/Owings Mills area located in 1st class medical building seeks motivated individual to work PART-TIME. Must be surgically trained. Must have a great personality and a good sense of humor. State-of-the-art office with hospital-grade ASC. Good mix of general podiatry, sports medicine and surgery. Competitive salary. Benefits for malpractice and health insurance allowances are available and negotiable. Please forward your CV by fax to 410-602-9781 or by email at mwaiken@comcast.net

ASSOCIATE - METRO NEW YORK--LONG ISLAND & NEW YORK CITY

Excellent Opportunity for immediate partnership with established practice. Excellent Salary arrangement, serious inquiries only. Send CV along with response. E-mail: rrranch7@yahoo.com

ASSOCIATE POSITION - CHICAGO AREA

Join one of the most successful, long-established podiatry practices in the Chicago area, with excellent salary and benefits. We have an immediate opening for part-time podiatrist in a multi practice location in Chicago. Must have two years of surgical residency. Please e-mail resume to f-massuda@footexperts.com

ASSOCIATE POSITION –GEORGIA

A well-established practice in South Georgia seeks a full time PSR-24/36 trained podiatrist. Excellent benefit package. Please send CV to agriffin@southernpodiatry.com. For more information, visit our website

NJ PODIATRY PRACTICE WANTED

Two eager podiatrists are looking to acquire another podiatric practice in New Jersey. Not interested in a partnership, just a complete buy out. The practice must be participating with Aetna. If interested, please call (917) 301-1919 or e-mail at NJFootDoc@hotmail.com

ASSOCIATE MONTANA

Great opportunity for a PSR-24 or 36 residency trained individual to join a dynamic two doctor group with physical therapy. Needs good FF surgical skills, RF a bonus. Beautiful office and great area of the country for outdoor recreation minded individuals. Opportunity for partnership after employment. Reply to: jclough@sofast.net

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